DOCTOR’S ORDER SHEET

NAME: Patient G.B. AGE: 67 y/o HOSPITAL NO.: 2478982

SERVICE: SEX: M WARD/RM: Medical Ward

ATTENDING PHYSICIAN: Mr. Han Smith

DATE/TIME/PROGRESS NOTES ORDERS

12/15/21 Please admit to Medical Ward
10:30 AM
BP- 110/70 mmHg
PR-68 bpm
RR-24/min
O2 SAT-88%
Secure consent for care & management

TPR q 4h & record

DAT with SAP

Problem: Fever, chills, rapid labored respirations, and chest

pain when he takes a deep breath or coughs.
Diagnostics: CBC, ABG analysis, Chest x-ray, pH, & pulmonary
function studies.

IVF: PNSS 1L regulated at 20 gtts/min

O2 inhalation via face mask at 8L/min

Encourage to take a deep breath, hold for 2 secs, and cough

2 or 3 times in succession

Encourage use of incentive spirometry: 10 blows, 10 times

daily (total 100 blows), as appropriate.

Monitor client’s respiratory secretions.

 Medications:
1. Tab Tempra 325 mg P.O. q4h
2. Tab Mucinex 600 mg P.O. q AM
3. NEB Combivent 2 puffs (3 mL inhaled q6hr) QID,
then reasses (each nebule diluted with 1cc of sterile
water/PNSS)
Place on moderate high back rest

Place on orthopneic position

Monitor O2 saturation

Suction secretions as needed.

Monitor I & O q shift.

Pls. relay lab & diagnostics results once available.

For close monitoring.

12/16/21 Refer client to nutritionist, dietary counseling

10:00 AM
BP- 120/80 mmHg
PR-70 bpm
RR-22/min
O2 SAT-90%
Refer to pulmonologist for COPD and potential pneumonia.
Refer to smoking cessation program

THIS IS STRICTLY FOR SIMULATION PURPOSES ONLY.

Doctors Order Sheet includes:

Admitting/Transfer Orders

Laboratory and diagnostics Procedures

Medical management (surgical operations, medications, treatment plan, etc.)

Referrals